Abstract
Facing an aging population and rising government expenditures, US health care is rapidly moving toward value-based care. Our physician payment model is changing from fee for service to transparent performance metrics, including outcomes and patient-reported experience measures. 1 The changing payment structure will require a new care model to facilitate health care systems delivering superior care, a better experience for patients, and lower costs. There is an opportunity for financial reward for providers in an alternative payment model focused on quality metrics. 2 However, success of an alternative payment model, such as an accountable care organization or bundled payment initiative, requires significant physician engagement.
Beginning in 2013, our cardiac surgeons collaborated with our hospital in the Bundled Payments for Care Improvement Initiative for all isolated coronary artery bypass grafting procedures covered by Medicare. We learned the value of enlisting, securing, and fostering continued physician engagement. Early identification of a physician leader (PL)—who can listen, engage, and lead other colleagues—to be an early adopter and to have a significant role in care redesign is necessary. This physician must be equipped with training and tools to lead others, and will require dedicated protected time and the autonomy to coordinate and implement changes. The most important tasks are as follows:
Ensure Coordination of Care
A multidisciplinary group of advanced practitioners, residents, nurses, pharmacists, and rehabilitation and respiratory therapists is identified by the lead physician as the only means to ensure essential coordination of care. Physicians must have a consistent message to patients, families, and staff regarding expectations during the entire episode of care. Working with the PL, a dedicated care coordinator identifies hospital barriers to a timely discharge, beginning with preoperative education on length of stay expectations and emphasizing the need for family support at home on discharge.
Ensure Complete and Correct Coding
The PL must ensure patient severity is accurately reflected in the daily documentation. Providers must document to correctly and accurately report the level of acuity and major comorbidities. This will positively affect both reimbursement and the expected morbidity and mortality rate and ensure precise local and national benchmarking.
Encourage Peer Comparison and Outcomes Transparency
It is essential to maximize transparency and identify relevant metrics within the service line. Physicians need to visualize differences in cost and outcomes and how each physician’s performance compares to others. Utilizing peer comparisons can motivate change and drive down hospital costs because physicians dislike being outliers.
Using Medicare-supplied claims and data available from hospitals, surgical practices, and post-acute care providers, physicians can measure and manage performance. The data must be up-to-date, organized, and benchmarked to highlight opportunities across the care continuum. Monthly bundled model of care and performance improvement meetings must utilize custom graphic trend and benchmark displays to highlight deficiencies. Reducing unnecessary care variation is a priority. Early in the process, it is important to emphasize one low-risk/high-reward metric with available benchmarks as a focused change in practice. An early success based on real-time data analytics will help drive future quality care and patient care improvements toward reduction in costs and standardization.
Physicians appreciate positive feedback and worry about losing the respect of their colleagues. Health systems increasingly report feedback to physicians regarding outcomes, patient experience, and costs. Competitive by nature, physicians will push each other to improve quality if provided a meaningful, mutually agreed on set of goals and measures. This shared purpose produces conversations around improving performance and outcomes.
Emphasize the Post-Acute Disposition
The post-acute disposition was the single greatest variable affecting a positive margin in our cardiac surgical bundle. When speaking with patients, physicians typically emphasize the index procedure and possibly the hospitalization, but typically neglect discussing post-acute expectations. We emphasize the benefits of patients returning home versus to a skilled nursing facility (SNF). By altering the patient and family expectations, providing frequent daily mobilization, and possibly extending inpatient stays for an extra day, the percentage of patients discharged directly to home increased.
For patients sent to an SNF, close coordination with the facility decreased the post-acute length of stay, thereby reducing overall costs to the bundle, and improving patient satisfaction. We have developed a preferred provider SNF network to closely align with best practice standards, track outcomes, and improve communication between the primary inpatient team and our post-acute care partners.
Prevent Readmissions
To succeed in a bundled payment arrangement, one must reduce readmissions. Patients at higher risk of recidivism are identified by the engaged physician prior to discharge. After patients’ discharge home, close follow-up by phone with daily weights, medication reconciliation, and early postoperative appointments prevented emergency department visits. The engaged physician must guarantee these patients will be seen during business hours, on the same day if necessary. If a postoperative patient enters our emergency department, this triggers an electronic notification to our inpatient service for expedited review and disposition by the engaged physician. All readmissions are scrutinized closely for potentially avoidable events.
Once the physician-led team has initial success in care coordination, outcomes, and cost reduction, the hospital should consider adding the following 4 ingredients to the “Secret Sauce”: merit, appreciation, equality, and growth.
Merit: Promoting Success and Celebrating Achievement
Sharing small successes with other leaders in an organization can stimulate more innovation toward value-based care. Physicians feel pride in providing the best care to their patients, and engaging them at this level will improve participation. Positive feedback is a great professional motivator. Social media can be used to share small successes with the ancillary support staff to further engagement. Creating a hospital-wide President’s Excellence Award and ceremony to publicize quality accomplishments will highlight the efforts of the newly engaged physician and his/her team. Promoting these successes and any other local, regional, and national hospital quality awards, analytics, and honors will further increase engagement.
Appreciation: Providing Incentives and Outlining Expectations
Though compensation is a relatively poor driver for change, it is essential to develop appropriate incentives to reward engaged physicians for their time and flexibility. A provider agreement should be formulated that outlines physician expectations and includes rewards for outcomes, performance, and collaboration. Physicians who can demonstrate improvements in patient care and eliminate unnecessary tests, medications, and services that do not provide patient value need to be at the center of the incentive plan. The bundled payment initiatives have legalized gainsharing to economically align physicians, hospitals, and payers.
Equality: Sharing Risk
Physicians should have “some skin in the game.” Organizations should put a percentage of compensation at risk for actively participating and/or achieving quality metrics. Incentives based on productivity alone conflict with a value-based model. Instead, compensation that promotes highly efficient, population health-oriented care will lead to improved commitment.
Growth: Fostering Leadership Through Formal Training and Mentorship
The engaged PL requires training in governance, leadership, and medical economics. Attendance at a focused physician leadership/health care economics conference will be beneficial. Physicians need to clearly understand regulatory and industry changes, the organization’s shared goals, and the personal and professional impact of these changes. Concepts such as HCC (Medicare’s Hierarchical Condition Category coding), 2-sided risk, and attribution need to be taught to engaged physicians. Sending a physician-led multidisciplinary team to annual conferences to share common challenges in value-based health care will both educate and energize these essential partners. Encouraging the PL to share best practices with colleagues will further involvement.
Mentoring is another way to enhance physician obligation. As the PL matures, he or she will transition from being the mentee to mentoring to junior staff. The mentoring process is a 2-way collaboration that improves job satisfaction for both participants. It also will ensure long-term success on the journey to value-based care.
Physicians need to be engaged leaders, not physician champions. A physician champion advocates others’ ideas. Engaged physicians have the autonomy to set their own strategy to realize a goal. With true ownership and the ability to see the positive impact on their patients and the organization as a whole, the physician will be well engaged. These physicians bring energy and enthusiasm to the workplace, are committed to both their patients and the institution, and are essential to success in any alternative payment model of value-based care.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.